Given the promise of a cost-effective strategy provided by Barnieh’s group—and a lack of empirical evidence that ethical concerns about incentivizing live donors would manifest—we propose a research agenda and necessary elements for a limited trial of incentives. First, using modeling, researchers should examine the comparative effectiveness of different incentive strategies, such as reimbursement for lost wages and expenses or provision of insurance. Expense reimbursement is a promising alternative to fixed payment. Estimates of donor financial burden range from $907 to $3089, and compensation would help ensure that donors do not suffer financially from donation (8). Because potential donors would not stand to benefit financially, expense reimbursement could ease concerns about undue and unjust inducement, but it might also fail to generate a meaningful increase in the supply of organs (5). Moreover, in contrast with fixed payment for donation, expense reimbursement is legal in the United States (1).

Second, a limited, real-world trial of regulated incentives should be conducted. Ideally, the effect of a direct payment intervention could be contrasted with expense reimbursement and usual care. A geographically limited trial should assess (1) the effect of different payment models on the number of donors (to assess the program’s benefits), (2) the socioeconomic and general health status of potential and actual donors (to assess unjust inducement), and (3) donor comprehension of risks and evidence of donor coercion (to assess undue inducement). If incentives are provided for only a subset of donors, evidence of crowding out should also be assessed. The trial should measure psychological, financial, and physical outcomes after donation. Existing protections for potential live donors will be necessary, such as use of independent donor advocates, separation of donor and recipient evaluation teams, and ability to opt-out from donation with dignity at any time (5). Additional protections may also be needed, such as a “cooling off” period between evaluation and donation to allow transplant teams multiple opportunities to assess donor motives and comprehension.

The barriers to conducting such a trial are significant. In the United States, these barriers include the National Organ Transplant Act (1). Removing the legal prohibition on payment for donation would require persistent advocacy by diverse stakeholders. So far, surveys suggest a lack of consensus for organ markets among the general public, and a minority of transplant surgeons support paying for living donation (9,10).

Current trends regarding the use of financial incentives in medicine suggest that the time is ripe for new consideration of payments for living kidney donation. The last decade has witnessed rising interest in behavioral economics and well-designed clinical trials using financial incentives to change diverse health behaviors, including smoking and weight loss (11–13). In the meantime, this work by Barnieh et al. may allow advocates to make a financial case for incentives in the realm of living kidney donation. Reassurance about the ethical concerns, however, can come only through empirical evidence from actual experience.